U.S. DOD Form dod-dd-137-5
CONTROL NUMBER
DEPENDENCY STATEMENT INCAPACITATED CHILD OVER AGE 21
Form Approved
OMB No. 0730-0014
Expires Sep 30, 2007
The public reporting burden for this collection of information is estimated to average 1.25 hours per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0730-0014). Respondents should be aware
that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB
control number.
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO YOUR LOCAL SERVING PERSONNEL/PAYROLL
OFFICE.
PRIVACY ACT STATEMENT
AUTHORITY: Executive Order 9397, November 1943; 37 U.S.C. Chapter 7; 10 U.S.C. Chapter 55; and Department of Defense Financial
Management Regulation (DoDFMR) 7000.14-R, Vol. 7A, Military Pay Policy and Procedures - Active Duty and Reserve Duty.
PRINCIPAL PURPOSE(S): The information provided on this form will be used to determine the relationship and dependency of an individual on
the military member, for entitlement of authorized benefits.
ROUTINE USE(S): The information on this form may be disclosed as generally permitted under 5 U.S.C. Section 552a(b) of the Privacy Act, as
amended. It may also be disclosed outside of the Department of Defense to the Internal Revenue Service (IRS) for tax purposes, and the
Department of Veterans Affairs (DOVA) regarding DOVA compensation. Other Federal, State, or local government agencies, which have
identified a need to know, may obtain this information for the purpose(s) identified in the DoD Blanket Routine Uses as ppublished in the
Federal Register.
DISCLOSURE: Voluntary; however, failure to provide this information will result in a suspension of the dependent entitlement until the military
member provides the required certification.
INSTRUCTIONS
The member must complete the form in its entirety, sign and date the form, and have it notarized. If the child resides alone or with
someone other than the member, the member completes Items 1, 2, and 16, signs and dates the form, and the child or child's representative
completes Items 3 through 15, signs and dates the form, and has it notarized. If the member is deceased, the child or child's representative
completes the form in its entirety, signs and dates the form, and has it notarized. Information furnished must reflect the 12 months prior to
member's death. Verification of income is required.
NOTE: Answer all questions. If any question does not apply, write "NOT APPLICABLE" or "N/A" in that block. Use the Remarks section
when required. Incomplete answers will delay final action on the application.
1. ENTITLEMENTS REQUESTED (X and complete as applicable)
a. TYPE
BAH
b. FIRST APPLICATION?
USIP CARD
TRAVEL ALLOWANCE
c. LAST APPLICATION WAS
YES
(If No, give date of last application)
APPROVED
NO
(YYYYMMDD)
DISAPPROVED
2. MEMBER INFORMATION
a. NAME (Last, First, Middle Initial)
b. SSN
c. RANK
d. STATUS (X and complete as applicable)
ACTIVE DUTY
NATIONAL GUARD
ARMY
NAVY
DECEASED (Date of death) (YYYYMMDD)
RETIRED
RESERVE
MARINE CORPS
AIR FORCE
OTHER (Specify)
e. COMPLETE RESIDENCE ADDRESS (Street, Apartment Number, City, State, ZIP Code)
f. COMPLETE MILITARY ADDRESS (Include assignment: squadron and base)
g. TELEPHONE NUMBERS (Include DSN or Area Code)
(1) WORK
h. E-MAIL ADDRESS
i. MARITAL STATUS (X one)
(2) HOME
SINGLE
SEPARATED
MARRIED
DIVORCED
WIDOWED
3. MEMBER'S CHILD
a. NAME (Last, First, Middle Initial)
b. SSN
c. DATE OF BIRTH (YYYYMMDD)
d. RELATIONSHIP TO MEMBER (X one)
LEGITIMATE CHILD
CHILD BORN OUT OF WEDLOCK
e. COMPLETE ADDRESS (Street, Apartment Number, City, State, ZIP Code)
ADOPTED CHILD
STEPCHILD
f. HAS CHILD EVER BEEN MARRIED? (If Yes, attach a copy of annulment
decree, final divorce decree, or death certificate of child's spouse.)
YES NO DD FORM 137-5, OCT 2004
PREVIOUS EDITION IS OBSOLETE.
Page 1 of 5 Pages
4. CHILD'S OTHER PARENT(S)
a. (1) NAME (Last, First, Middle Initial)
b. (1) NAME (Last, First, Middle Initial)
((2) RELATIONSHIP TO CHILD
((2) RELATIONSHIP TO CHILD
(3) COMPLETE ADDRESS (Street, Apartment Number, City, State, ZIP Code)
(3) COMPLETE ADDRESS (Street, Apartment Number, City, State, ZIP Code)
c. IS/ARE OTHER PARENT(S) IN ANY BRANCH OF SERVICE, INCLUDING RESERVE OR NATIONAL GUARD (X one)
(If Yes, show rank, name, SSN, and military address.)
YES
d. DOES OTHER PARENT CLAIM CHILD FOR BASIC ALLOWANCE FOR HOUSING (BAH), TRAVEL ALLOWANCE, OR USIP CARD (X one)
(If Yes, explain.)
NO
YES
NO
5. CHILD'S RESIDENCE
a. TYPE OF RESIDENCE (X and complete as applicable)
HOME OR APARTMENT OF FRIEND OR RELATIVE (State relationship)
HOME OR APARTMENT OF OTHER PARENT
HOME OR APARTMENT OF MEMBER
HOME OR APARTMENT OF CHILD
HOSPITAL OR INSTITUTION
HOME OR APARTMENT OF FORMER SPOUSE OF MEMBER
OTHER (Explain)
STUDENT DORMITORY OR OTHER ON-CAMPUS FACILITY
b. OWNER OF RESIDENCE
(1) NAME (Last, First, Middle Initial)
(2) ADDRESS (Street, Apartment Number, City, State, ZIP Code)
c. IS RESIDENCE SUBSIDIZED HOUSING?
d. DATE CHILD STARTED LIVING AT CURRENT ADDRESS (YYYYMMDD)
YES
NO
6. IF CHILD IS IN HOSPITAL OR INSTITUTION
If child is in a hospital or institution, all of the following information must be furnished. Obtain this information from the hospital or
institution.
a. DATE CHILD ENTERED HOSPITAL/INSTITUTION (YYYYMMDD)
b. ANTICIPATED DATE OF DISCHARGE (If known)
c. WILL CHILD RETURN TO MEMBER'S HOME AFTER DISCHARGE? (If "NO," explain where child will reside)
YES
NO
d. CHILD'S EXPENSES IN HOSPITAL OR INSTITUTION
ITEM
PRESENT MONTHLY
EXPENSE
TOTAL EXPENSE FOR
PAST 12 MONTHS
ITEM
(1) ROOM
(8) EDUCATION
(2) FOOD
(9) TRANSPORTATION
(3) REHABILITATION CLASSES
OR SERVICES
PRESENT MONTHLY
EXPENSE
TOTAL EXPENSE FOR
PAST 12 MONTHS
(10) PERSONAL INSURANCE
(Specify)
(4) SPECIALIZED EQUIPMENT
(11) OTHER (Specify)
(5) MEDICAL CARE
(6) CLOTHING
(7) LAUNDRY/DRY CLEANING
DD FORM 137-5, OCT 2004
Page 2 of 5 Pages
6. IF CHILD IS IN HOSPITAL OR INSTITUTION (Continued)
e. CHILD'S EXPENSES IN HOSPITAL OR INSTITUTION ARE PAID BY:
SOURCE
(1)
U
S
I
P
C
A
R
D
PRESENT MONTHLY
EXPENSE
TOTAL EXPENSE FOR
PAST 12 MONTHS
PRESENT MONTHLY
EXPENSE
SOURCE
(a) CIVILIAN MEDICAL
TREATMENT FACILITY
(CHAMPUS)
(3) STATE OR LOCAL AGENCY
(Give name and address
in Remarks section)
(b) MILITARY MEDICAL
TREATMENT FACILITY
(4) MEMBER
TOTAL EXPENSE FOR
PAST 12 MONTHS
(5) OTHER (Explain and give
name and address in
Remarks section)
(2) PRIVATE INSURANCE
(Give name and address
in Remarks section)
7. PERSONS LIVING IN HOUSEHOLD WITH CHILD
When child resides in a hospital or institution and Item 6 is completed, do not complete this item. List all persons who live in the
household, including claimed child. If employed, show hours per week worked. Continue in Remarks if more space is needed.
a. NAME (Last, First, Middle Initial)
b. RELATIONSHIP
TO CHILD
c. AGE
d. MARRIED (X)
YES
NO
e. EMPLOYED
HOURS PER WEEK
NO (X)
8. HOUSEHOLD EXPENSES
When child resides in a hospital or institution and Item 6 is completed, do not complete this item. List the household expenses for all
persons living in the home. If expense was one-time only, such as purchase of a new chair, do not show this as a monthly expense; list it as an
expense for the past 12 months. If child resides in the member's household or in a dwelling owned by the member, use Fair Rental Value (FRV)
for dwelling. If child does not reside in member's household or in a dwelling owned by member, list actual mortgage, rent, or FRV if dwelling is
mortgage-free. If FRV is used, give a brief explanation of how Fair Rental Value was obtained using the Remarks section.
FAIR RENTAL VALUE (FRV): FRV is a single monthly sum for the entire dwelling where the child lives. This sum is an amount the owner
can reasonably expect to receive from a stranger to rent the dwelling. FRV will not include food, utilities, furniture, and home repairs, which are
listed separately.
ITEM
(1)
PRESENT MONTHLY
EXPENSE
(2)
TOTAL EXPENSE FOR
PAST 12 MONTHS
a. (X one)
ITEM
(1)
PRESENT MONTHLY
EXPENSE
(2)
TOTAL EXPENSE FOR
PAST 12 MONTHS
d. FURNITURE AND
APPLIANCES
RENT
FRV
MORTGAGE
(Specify amount of tax and
insurance if applicable)
e. REPAIRS ON HOME
TAX
INSURANCE
b. FOOD
f. OTHER (Itemize in Remarks
section)
c. UTILITIES (Heat, power,
water, and telephone)
9. CHILD'S PERSONAL EXPENSES
When child resides in a hospital or institution and Item 6 is completed, do not complete this item. List all of the child's personal expenses
regardless of who is paying for them.
ITEM
(1)
PRESENT MONTHLY
EXPENSE
a. CLOTHING
b. LAUNDRY AND DRY
CLEANING
c. MEDICAL (Do not include
expenses paid by insurance,
welfare, or Medicare)
d. VALUE OF USIP CARD
(Verification of amount is
required)
(2)
TOTAL EXPENSE FOR
PAST 12 MONTHS
ITEM
(1)
PRESENT MONTHLY
EXPENSE
(2)
TOTAL EXPENSE FOR
PAST 12 MONTHS
g. PRIVATE AUTO PAYMENTS
(If auto is registered in
child's name)
h. MONTHLY TRANSPORTATION PAYMENTS (Specify
type)
i. SCHOOL EXPENSES
j. OTHER (Specify)
e. PERSONAL INSURANCE
(Specify)
f. PERSONAL TAXES (Specify)
DD FORM 137-5, OCT 2004
Page 3 of 5 Pages